Sunday, October 25, 2009

Pilots Lost Situation Awareness

By now you have probably heard about Northwest flight 188. The flight’s destination was the Minneapolis-St. Paul International airport. However, for reasons that have yet to be revealed, the pilots remained at 37,000 feet and flew right past the airport. It took over an hour for them to realize what they had done and correct the error. Air traffic controllers were trying desperately and unsuccessfully to reach them. Military jets were put on standby. The White House was alerted. How could this happen?

Initial accounts say the pilots were engaged in a heated disagreement over airline policy. A subsequent report said the pilots may have been sleeping. The National Transportation Safety Board will sort all that out. What we do know is the pilots lost situation awareness and mistakes were made. How could this happen?

This incident may have left you surprised or angry. After all, you don’t want to think the very people you entrust your life to are not paying attention when they’re flying the plane. I look at it a little differently. For years I have immersed myself in the study of situation awareness in dynamic, high-risk, high consequence environments and corresponding research in neuroscience and cognitive psychology. Admittedly, it’s not the kind of reading that most of you would find enjoyable, but I do.

One of the things I have learned is there are barriers to situation awareness – stated simply – things that impact your ability to pay attention. In research I conducted with fireground commanders, I was able to identify 116 potential barriers to a fireground commander’s situation awareness. With so many potential barriers, you might wonder how commanders maintain situation awareness at an emergency scene.

Many times when a near-miss or catastrophic event occurs, a loss of situation awareness is among the culprits. That’s because it’s not as easy to pay attention as you think. In addition to the things that happen around you that can draw you off task, there are a number of things happening in your brain that work against you. From my research, I have developed a training program to help public safety personnel understand what situation awareness is, how to develop it, maintain it, and how to regain it when it’s lost. I have been humbled by the number of requests I have received to present the findings of my research to firefighters throughout the United States, Canada, and England. If you want to taste of the program, I’ve posted some clips on my website. I’ve also produced a DVD series and wrote a book on the subject. I am passionate about improving fireground command decision making and situation awareness.

Pilots lose their situation awareness, overshoot the airport, and it results in an investigation to understand what happened so the lessons can be applied industry-wide to help prevent a future occurrence. A fireground commander loses situation awareness, makes a bad decision that results in a near-miss, and what happens? What’s done to correct the problem? Educate? Change behavior? Share industry-wide?

Fire Chief (ret.) Richard B. Gasaway, PhD, EFO, CFO, MICP

[Note: This article is also posted on the Kitchen Table blog.]

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